2022 Convention Registration

Use this form to:
Sign Up to Attend
(Use other form if wanting to pay with credit card)

No group registration. Please apply individually.

Real inclusion means that people with disabilities have equal access to information and support to understand and use it in their own lives.

Is someone helping you fill out this form?

No Yes, they are including me. Yes, they are including me and you may contact them when you can't get hold of me:

Name of the person filling out this form for the applicant:

Email of the person filling out this form for the applicant:

Phone number of the person filling out this form for the applicant:

Please include area code

Name *

First Name Last Name

Address

Street Address

Apartment Number

City State

Postal / Zip Code

Phone Number *

Please include area code

Email

Emergency Contact:

Emergency Phone Number:

Caregiver who is coming with you to the convention (caregivers are free):

Name, if you know it. Otherwise, just type "Caregiver."

Phone Number, if you have it.

Who will you be sharing a room with?

No one. It will be just me. Just my caregiver. I will be sharing a room with others.

Please list everyone you will be sharing the room with here:

If you have a dietary preference, please let us know specifics:

None My dietary preference is:

Would you like us to know about any allergies or other conditions such as such as blood sugar, food or other allergies, seizures, etc. that may put you at risk of emergency? Also do you have any general safety or other concerns you'd like us to know?

Accessibility and/or accommodation requests:

I do NOT have accessibility and/or accommodation requests. I DO have accessibility and/or accommodation requests.

My Accessibility Requests are:

Please let us know if you will be bringing a pet.

I will be bringing my service animal. I will be bringing a therapy or other pet.

Ocean Shores is only reachable by private vehicle. Let's help each other get there!

I'll get there on my own. I'm making travel plans with my chapter. I don't know how I'm going to get there and would like help. I'm driving and might be able to offer a ride for the following number of people:

I know someone willing to volunteer to drive a rental vehicle for People First of Washington if needed. Their name and phone number is:

The following information is optional:

Age:

18 and under 18-21 22-30 31-40 41-50 51 or above I prefer not to say

I identify as:

Female Male I prefer not to say I am:

I am:

Asian Black Latino Multi-Racial Native American White I prefer not to say I am:

Living Situation:

Live on Own With Parents Live with Partner and/or Children Adult Family Home Supported Living I prefer not to say My situation is:

Do you give us permission to use your name, image and any videos in the zoom live-stream convention, social media, newsletters, and on the website, etc.?

Yes, I give People First of Washington permission. No, I don't give People First of Washington permission. Please share my information with the advisor in my local area and feel free to reach out or call me.

Please feel free to share any additional information you'd like us to know:

If you have any additional questions, please contact:
Robert Martin at 206-660-9236 or robert@pfow.org.

I will attend the convention:

Through the People First Zoom Room In-Person

Attending the convention costs $350 for In-Person and $100 for Virtual.

My chapter will pay for me. I will have a scholarship. I need a scholarship if one is available. I am a caregiver. I will send a check (mail to: People First of Washington, P.O. Box 1180, Spanaway, WA 98387-9997), or will contact Robert Martin at robert@pfow.org to make other arrangements.

If you have a scholarship and know the amount, enter it here:

Please tell us who donated your scholarship:

To complete this registration, type your name here:
blank*

Signature Date: *

Month Day Year

We want to make sure everyone is included in People First of Washington activities. If you have any questions, please contact the People First of Washington office at 253-999-7222.

Use this form to: Sign Up to Attend (Use other form if wanting to pay with credit card)

Use this form to:
Sign Up to Attend
(Use other form if wanting to pay with credit card)